Pathophysiology of lower urinary tract symptoms in aged men without bladder outlet obstruction

Urethral Sphincter Botulinum Toxin A Injection for Non-Spinal Cord Injured Patients with Voiding Dysfunction without Anatomical Obstructions: Which Patients Benefit Most?

OBJECTIVE

Treating voiding dysfunction without anatomical obstructions is challenging. Urethral onabotulinum toxin A (BoNT-A) is used in treating voiding dysfunction; however, the success rate varies widely, and patients may not be satisfied with the treatment outcome. This study compared the efficacy of the urethral BoNT-A injection between patients with different non-spinal cord injury (SCI) voiding dysfunctions.

MATERIALS AND METHODS

This study retrospectively analyzed patients with refractory voiding dysfunction, including detrusor underactivity (DU), dysfunctional voiding (DV), and poor relaxation of the external sphincter (PRES) who received the urethral sphincter 100 U BoNT-A injection. The treatment outcomes were assessed via a global response assessment (GRA) one month after treatment. Baseline and follow-up videourodynamic study (VUDS) parameters were also compared.

RESULTS

Totally, 161 patients (60 with DU, 77 with DV, and 24 with PRES) with a mean age of 58.8 ± 20.2 were enrolled, of which 62.1% had a good response (GRA ≥ 2) after urethral BoNT-A injection. DV patients had a higher success rate (76.6%) than DU (50%) and PRES (45.8%) patients (p = 0.002). A diagnosis of DV, higher voided volume and recurrent urinary tract infection were predictors of a good treatment response, while the cervical cancer status post-radical surgery predicted a poor response. Receiver operating characteristic (ROC) curve analyses identified PVR > 250 mL as a negative predictor (p = 0.008) in DU patients.

CONCLUSIONS

The urethral BoNT-A injection provides a satisfactory success rate for non-SCI voiding dysfunction. Patients with DV benefit most from both subjective and objective parameters. Approximately 50% of patients with DU and PRES also had a fair response. PVR > 250 mL was a negative predictor in DU patients.

Therapeutic Efficacy of Urethral Sphincteric Botulinum Toxin Injections for Female Sphincter Dysfunctions and a Search for Predictive Factors

External urethral sphincter (EUS) dysfunction is a common, bothersome female voiding dysfunction. This study aims to analyze the characteristics of different types of female EUS dysfunction, as well as to determine the outcome predictors of sphincteric botulinum toxin A (BoNT-A) injection. Women receiving sphincteric BoNT-A injections for refractory EUS dysfunction were retrospectively reviewed. A comparison of the baseline clinical, urodynamic parameters and the treatment responses were made for patients with different EUS dysfunctions. A total of 106 females were included. Significantly increased detrusor overactivity, detrusor contracting pressure and the bladder outlet obstruction index with decreased urge sensation were noted in patients diagnosed with dysfunctional voiding or detrusor sphincter dyssynergia comparing to those diagnosed with poor relaxation of the external urethral sphincter. The average subjective improvement rate was 67% for the injection. The therapeutic effect was not affected by the type of EUS dysfunction. The multivariate analysis revealed that bladder neck narrowing and catheterization history were predictive of negative outcomes. There is a distinct urodynamic presentation for each type of female EUS dysfunction. Sphincteric BoNT-A injection provides a good therapeutic outcome for refractory EUS dysfunction. A narrowing bladder neck and a history of catheterization suggest poor therapeutic outcomes.

Therapeutic Effect of Botulinum Toxin A on Sensory Bladder Disorders-From Bench to Bedside

Bladder oversensitivity arises from several different conditions involving the bladder, bladder outlet, systemic or central nervous system diseases. Increase of the bladder sensation results from activation of the sensory receptors in the urothelial cells or suburothelial tissues. Medical treatment targeting the overactive bladder (OAB) or interstitial cystitis (IC) might relieve oversensitive bladder symptoms (frequency, urgency and pain) in a portion of patients, but a certain percentage of patients still need active management. Botulinum toxin A (BoNT-A) has been demonstrated to have anti-inflammatory and antinociceptive effects in bladder sensory disorders and has been shown effective in the reduction of bladder oversensitivity and the increase of functional bladder capacity. For patients with OAB, urgency and urinary incontinence improved, while in patients with IC, bladder pain could be relieved in association with reduction of bladder oversensitivity after BoNT-A intravesical injection. Histological evidence has confirmed the therapeutic mechanism and clinical efficacy of intravesical BoNT-A injection on patients with OAB or IC. Bladder oversensitivity can also be relieved with the instillation of liposome encapsulated BoNT-A or low energy show waves (LESWs), which enable the BoNT-A molecule to penetrate into the urothelium and suburothelial space without affecting the detrusor contractility. Liposome encapsulated BoNT-A or combined LESWs and BoNT-A instillation might be future treatment alternatives for bladder oversensitivity in sensory bladder disorders.

The Therapeutic Effects and Pathophysiology of Botulinum Toxin A on Voiding Dysfunction Due to Urethral Sphincter Dysfunction

Neurogenic and non-neurogenic urethral sphincter dysfunction are common causes of voiding dysfunction. Injections of botulinum toxin A (BoNT-A) into the urethral sphincter have been used to treat urethral sphincter dysfunction (USD) refractory to conventional treatment. Since its first use for patients with detrusor sphincter dyssynergia in 1988, BoNT-A has been applied to various causes of USD, including dysfunctional voiding, Fowler’s syndrome, and poor relaxation of the external urethral sphincter. BoNT-A is believed to decrease urethral resistance via paralysis of the striated sphincter muscle through inhibition of acetylcholine release in the neuromuscular junction. Recovery of detrusor function in patients with detrusor underactivity combined with a hyperactive sphincter also suggested the potential neuromodulation effect of sphincteric BoNT-A injection. A large proportion of patients with different causes of USD report significant improvement in voiding after sphincteric BoNT-A injections. However, patient satisfaction might not increase with an improvement in the symptoms because of concomitant side effects including exacerbated incontinence, urinary urgency, and over-expectation. Nonetheless, in terms of efficacy and safety, BoNT-A is still a reasonable option for refractory voiding function. To date, studies focusing on urethral sphincter BoNT-A injections have been limited to the heterogeneous etiologies of USD. Further well-designed studies are thus needed.

Current consensus and controversy on the diagnosis of male lower urinary tract symptoms/benign prostatic hyperplasia

Traditionally, male lower urinary tract symptoms (LUTS) have been considered a synonym for benign prostate hyperplasia (BPH) because most male LUTS develops in aging men. Medical treatment should be the first-line treatment for BPH and surgical intervention should be performed when there are complications or LUTS refractory to medical treatment. Recent investigations have revealed that bladder dysfunction and bladder outlet dysfunction contribute equally to male LUTS. In the diagnosis of LUTS suggestive of BPH (LUTS/BPH), the following questions should be considered: Is there an obstruction? Are the LUTS caused by an enlarged prostate? What are the appropriate tools to diagnose an obstructive BPH? Should patients with LUTS be treated before bladder outlet obstruction is confirmed? This article discusses the current consensus and controversies in the diagnosis of LUTS/BPH.

Role of Bladder Dysfunction in Men with Lower Urinary Tract Symptoms Refractory to Alpha-blocker Therapy: A Video-urodynamic Analysis

OBJECTIVES

Lower urinary tract symptoms (LUTS) in men result from a complex interplay of pathophysiology, including bladder and bladder outlet dysfunction. This study retrospectively analyzed bladder dysfunction in men with LUTS based on the results of video-urodynamic studies (VUDS).

METHODS

Male patients (aged ≥40 years), with LUTS and an International Prostate Symptom Score of 8 or more, who were refractory to alpha-blocker treatment were retrospectively recruited and evaluated with VUDS and total prostate volume (TPV). Patients were further divided into subgroups of bladder dysfunction and bladder outlet dysfunction according to characteristic VUDS findings. Age, TPV and VUDS findings were compared among different subgroups.

RESULTS

After VUDS, bladder outlet obstruction (BOO) was only noted in 48.6% of men. Of patients, 919 of 2991 (30.7%) had bladder dysfunction including detrusor underactivity (DU, 5.1%), detrusor overactivity and inadequate contractility (DHIC, 5.3%), detrusor overactivity (DO, 17%) and hypersensitive bladder (HSB, 3.3%). In addition, 1941 (64.9%) had bladder outlet dysfunction including BOO + DO (33.8%), BOO alone (14.8%), and poor urethral sphincter relaxation (PRES, 16.3%). Among the 1519 patients with DO, 66.6% (1012) had BOO while, among 1454 patients with BOO, 69.5% (1010) had DO. Patients with DHIC, DU and DO were 5 years older than patients with HSB and normal men. TPV was significantly smaller in patients with DHIC, DU and DO as compared with BOO + DO.

CONCLUSION

Approximately one-third of male LUTS was due to bladder dysfunction. A man older than 70 years with LUTS and TPV less than 30 mL usually indicates the presence of bladder dysfunction rather than BOO.

Role of Bladder Neck and Urethral Sphincter Dysfunction in Men with Persistent Bothersome Lower Urinary Tract Symptoms after α-1 Blocker Treatment

OBJECTIVE

To analyze the video-urodynamic results of voiding dysfunction in men of all ages with bothersome lower urinary tract symptoms (LUTS) after α-1 adrenoceptor blocker therapy.

METHODS

A total of 930 consecutive men over 45 years of age with LUTS who were failure treated with α-1 blocker therapy for at least one month were retrospectively studied. Patients underwent video-urodynamic studies to evaluate the cause of lower urinary tract dysfunction (LUTD). Clinical symptoms, prostatic measurements, and video-urodynamic findings were compared among different LUTD groups.

RESULTS

After video-urodynamic studies, 653 (70.2%) men were diagnosed with voiding dysfunction and 277 (29.8%) were with bladder dysfunction. Among patients with voiding dysfunction, bladder neck dysfunction (BND) occurred in 242 (37.1%), benign prostatic obstruction (BPO) in 298 (45.6%), and poor relaxation of the external sphincter (PRES) in 113 (17.3%). The symptom score did not differ significantly among the three subgroups. The mean age, total prostate volume (TPV), transition zone index, and prostate-specific antigen were also significantly higher in BPO patients compared with the other two subgroups, but no difference was noted between BND and PRES patients. BPO patients had significantly higher voiding pressure, higher Abrams-Griffiths number, lower Qmax, and a higher rate of detrusor overactivity than did patients in the other two subgroups.

CONCLUSION

Bladder neck dysfunction and PRES play important roles in male LUTS. In men younger than 70 years with small TPV and persistent LUTS after α-1 blocker therapy, video-urodynamic studies should be performed to make an accurate diagnosis before invasive surgery is planned.

Incidence and clinical characteristics of lower urinary tract symptoms as a presenting symptom for patients with newly diagnosed bladder cancer

PURPOSE

The incidence of lower urinary tract symptoms (LUTS) as the sole presenting symptom for bladder cancer has traditionally been reported to be low. The objective of this study was to evaluate the prevalence and clinical characteristics of newly diagnosed bladder cancer patients who presented with LUTS in the absence of gross or microscopic hematuria.

MATERIALS AND METHODS

We queried our database of bladder cancer patients at the Atlanta Veteran's Affairs Medical Center (AVAMC) to identify patients who presented solely with LUTS and were subsequently diagnosed with bladder cancer. Demographic, clinical, and pathologic variables were examined.

RESULTS

4.1% (14/340) of bladder cancer patients in our series presented solely with LUTS. Mean age and Charlson Co-morbidity Index of these patients was 66.4 years (range = 52-83) and 3 (range = 0-7), respectively. Of the 14 patients in our cohort presenting with LUTS, 9 (64.3%), 4 (28.6%), and 1 (7.1%) patients presented with clinical stage Ta, carcinoma in Situ (CIS), and T2 disease. At a median follow-up of 3.79 years, recurrence occurred in 7 (50.0%) patients with progression occurring in 1 (7.1%) patient. 11 (78.6%) patients were alive and currently disease free, and 3 (21.4%) patients had died, with only one (7.1%) death attributable to bladder cancer.

CONCLUSIONS

Our database shows a 4.1% incidence of LUTS as the sole presenting symptom in patients with newly diagnosed bladder cancer. This study suggests that urologists should have a low threshold for evaluating patients with unexplained LUTS for underlying bladder cancer.

Severity of lower urinary tract symptoms reflects different composition of bladder storage dysfunction and bladder outlet obstruction in men with symptomatic benign prostatic hyperplasia

AIMS

Differentiation of different lower urinary tract dysfunctions (LUTD) is essential for selecting the optimal first-line medical treatment of lower urinary tract symptoms (LUTS). This study analysed the association of the severity of LUTS with LUTD and therapeutic results based on the International Prostate Symptom Score (IPSS) voiding to storage (V/S) ratio.

MATERIALS AND METHODS

Lower urinary tract symptoms were evaluated in 849 men using the IPSS questionnaire and the IPSS-V/S ratio. The prostate measures, urinary flow measures, and C-reactive protein (CRP) were investigated at baseline and 1 month after treatment. Therapeutic results were assessed by changes in the quality of life index (QoL-I). The associations of the severity of LUTS with LUTD and therapeutic results were analysed.

RESULTS

Mild (IPSS ≤ 7), moderate (8 ≤ IPSS ≤ 19) and severe LUTS (IPSS ≥ 20) were noted in 215, 461 and 173 men. IPSS-V/S ≤ 1 was noted in 81.4% of patients with mild LUTS, while IPSS-V/S > 1 was noted in 71.1% of patients with severe LUTS. After treatment with alpha-blockers in patients with IPSS-V/S > 1 and antimuscarinic agents in patients with IPSS-V/S ≤ 1 for 1 month, 84.0% and 88.8% of patients with mild LUTS had effective therapeutic results, respectively. In contrast, the therapeutic results were less effective in patients with moderate (64.9% and 63.8%, respectively) or severe LUTS (50% and 33.3%, respectively).

CONCLUSION

Patients with benign prostatic hyperplasia (BPH) and mild LUTS have more bladder storage dysfunction, whereas patients with BPH and severe LUTS had higher grade of bladder outlet disorders in associated with storage symptoms. Treatment based on the IPSS-V/S ratio results in good therapeutic results in men with mild and moderate LUTS, but not in men with severe LUTS.

International Prostatic Symptom Score-voiding/storage subscore ratio in association with total prostatic volume and maximum flow rate is diagnostic of bladder outlet-related lower urinary tract dysfunction in men with lower urinary tract symptoms

OBJECTIVES

The aim of this study was to investigate the predictive values of the total International Prostate Symptom Score (IPSS-T) and voiding to storage subscore ratio (IPSS-V/S) in association with total prostate volume (TPV) and maximum urinary flow rate (Qmax) in the diagnosis of bladder outlet-related lower urinary tract dysfunction (LUTD) in men with lower urinary tract symptoms (LUTS).

METHODS

A total of 298 men with LUTS were enrolled. Video-urodynamic studies were used to determine the causes of LUTS. Differences in IPSS-T, IPSS-V/S ratio, TPV and Qmax between patients with bladder outlet-related LUTD and bladder-related LUTD were analyzed. The positive and negative predictive values (PPV and NPV) for bladder outlet-related LUTD were calculated using these parameters.

RESULTS

Of the 298 men, bladder outlet-related LUTD was diagnosed in 167 (56%). We found that IPSS-V/S ratio was significantly higher among those patients with bladder outlet-related LUTD than patients with bladder-related LUTD (2.28±2.25 vs. 0.90±0.88, p<0.001). TPV was similar between the two groups; however, in contrast to patients with bladder-related LUTD, patients with bladder outlet-related LUTD had higher detrusor voiding pressure, lower Qmax values, and greater postvoid residual volumes. The combination of TPV≥30 ml and Qmax≤10 ml/sec had a PPV of 68.8% and a NPV of 53.5% for bladder outlet-related LUTD. When IPSS-T≥12 or IPSS-T≥15 was considered as an additional criterion, PPV increased to 75.0% and 78.5%, respectively, and the NPV decreased to 50.9% and 50.2%, respectively. When IPSS-V/S>1 or >2 was factored into the equation instead of IPSS-T, PPV were 91.4% and 97.3%, respectively, and NPV were 54.8% and 49.8%, respectively.

CONCLUSIONS

Combination of IPSS-T with TPV and Qmax increases the PPV of bladder outlet-related LUTD. Furthermore, including IPSS-V/S>1 or >2 into the equation results in a higher PPV than IPSS-T. IPSS-V/S>1 is a stronger predictor of bladder outlet-related LUTD than IPSS-T.

Persistent detrusor overactivity in rats after relief of partial urethral obstruction

Detrusor overactivity (DO) persists after prostatectomy in 20% to 25% of patients with benign disease. Assuming that nonvoiding contractions (NVCs) can be used as a surrogate for DO in humans, the rat model of obstruction/deobstruction may allow us to study the pathophysiology of persistent DO after deobstruction. We investigated bladder function, with a special focus on NVCs, in rats by use of a new, modified method of obstruction and deobstruction and compared these results with those obtained by use of the conventional method. Seventy female Sprague-Dawley rats underwent 1) sham operation (n = 10), 2) obstruction by a modified method (Modif-Obs; n = 12), 3) obstruction/deobstruction by the conventional method (Conv-Obs/Deobs; n = 13), or 4) obstruction/deobstruction by the modified method (Modif-Obs/Deobs; n = 35). The Modif-Obs/Deobs animals were divided into subgroups with (DO+) and without (DO-) NVCs. Two weeks after partial urethral obstruction, the animals were deobstructed, and 1 wk later cystometry was performed with recording of intravesical and intra-abdominal pressures. NVCs were shown in all groups: Modif-Obs (80%), Conv-Obs/Deobs (100%), and Modif-Obs/Deobs (40%). In the Modif-Obs/Deobs group, bladder weight and the muscle-to-collagen ratio were higher in DO+ than in DO- rats. The Modif-Obs/Deobs group showed no mortality compared with 25% mortality in the Conv-Obs/Deobs group. The modified method may be more adequate for studying persistent DO after deobstruction, because it resulted in pressure/volume- and DO-related parameters similar to those found in the clinical situation. The persistence of DO after deobstruction may partly be due to irreversible changes in the bladder caused during the period of obstruction.

Causes of Failed Urethral Botulinum Toxin A Treatment for Emptying Failure

OBJECTIVES

Urethral injection of botulinum toxin A (BTX-A) can reduce urethral resistance in patients with voiding dysfunction. However, some patients do not benefit from this treatment. It is essential to identify the causes for these failed procedures.

METHODS

A total of 200 patients receiving urethral BTX-A injections for voiding dysfunction refractory to conventional medication during a 5-year period were included in this study. The patients received 50 or 100 U of BTX-A injected into the urethral sphincter. Treatment was considered successful when patients were subjectively satisfied with the outcome and (a) patients with chronic urinary retention resumed spontaneous voiding, (b) patients with a large postvoid residual volume had a reduction in postvoid residual of more than 50%, (c) patients voided with a lower detrusor pressure or lower abdominal pressure to urinate adequately. The therapeutic results and causes of failed treatment were retrospectively analyzed.

RESULTS

The overall success rate was 88.5% (177 patients), including 47.5% (95 patients) with an excellent result and 41% (82 patients) with an improved result. The causes of failed treatment in 23 patients were detrusor underactivity with very low abdominal straining pressure in 7, a tight urethral sphincter in 7, bladder neck obstruction in 7, and psychological inhibition of voiding in 2. Transurethral incision of the bladder neck was performed in 7 patients, and all had an improved result.

CONCLUSIONS

BTX-A urethral treatment failed in 11.5% of patients with voiding dysfunction refractory to medical treatment after one session. Careful investigation of the underlying causes of failed treatment is mandatory to achieve a satisfactory outcome.

Videourodynamic Analysis of Pathophysiology of Men with Both Storage and Voiding Lower Urinary Tract Symptoms

OBJECTIVES

Lower urinary tract symptoms (LUTS) are highly prevalent among men; however, not all men with LUTS have urodynamically confirmed bladder outlet obstruction. Overactive bladder symptoms are often caused by bladder dysfunctions alone or in combination with bladder outlet obstruction. A detailed diagnosis to identify the causes of LUTS in men seems mandatory to correctly target different therapy to the various underlying pathologic features.

METHODS

A total of 1407 male patients referred for investigation of LUTS were included in this study. All patients had both storage and voiding symptoms. A videourodynamic study was performed for the diagnosis of bladder dysfunction and bladder outlet dysfunction. The videourodynamic results were also correlated with patient age and compared with the presenting symptoms.

RESULTS

The videourodynamic study revealed that of the 1407 patients with bladder dysfunction, 148 (10.5%) had increased bladder sensation, 724 (51.5%) had detrusor overactivity, 149 (10.6%) had detrusor underactivity, and 82 (5.8%) had a combination of detrusor overactivity and detrusor underactivity. The causes of bladder outlet dysfunction included bladder neck dysfunction in 19 patients (1.4%), benign prostatic obstruction in 413 (29.4%), urethral sphincter pseudodyssynergia in 30 (2.1%), and poor relaxation of urethral sphincter in 283 (20.1%).

CONCLUSIONS

The results of this study have indicated that LUTS can result from a complex interplay of pathophysiologic features that can include bladder dysfunction and bladder outlet dysfunction such as benign prostatic obstruction or poor relaxation of the urethral sphincter. About one third of men with LUTS who were older than 55 years of age had benign prostatic obstruction. Patients younger than 55 years old were more likely to have poor relaxation of the urethral sphincter as a likely cause of LUTS.

Recovery of Detrusor Function After Urethral Botulinum A Toxin Injection in Patients with Idiopathic Low Detrusor Contractility and Voiding Dysfunction

OBJECTIVES

To investigate the effect of urethral botulinum A toxin (BoNT-A) injection on idiopathic low detrusor contractility and the correlation of this effect with baseline urodynamic parameters.

METHODS

Twenty-seven patients with idiopathic low detrusor contractility received urethral injection of BoNT-A. Videourodynamic studies were performed at baseline and after treatment. Recovery of detrusor contractility was defined as an increase in detrusor pressure and maximal flow rate and reduced postvoid residual urine volume. The therapeutic results and changes in urodynamic parameters were compared between patients with and without recovery of detrusor contractility.

RESULTS

The recovery of detrusor contractility after urethral BoNT-A injection occurred in 13 patients (48%). Patients with recovery of detrusor contractility had baseline data characterized by normal bladder sensation during bladder filling combined with a poor relaxation or hyperactive urethral sphincter activity. In contrast, patients without recovery of detrusor contractility had poor bladder sensation and a nonrelaxing urethral sphincter. Patients with baseline characteristics of low detrusor contractility combined with poorly relaxed or hyperactive urethral sphincter activity had better results than those with true detrusor underactivity. Of the 13 patients with recovery of detrusor contractility, 5 had a long-term therapeutic effect without the need of repeat urethral injection of BoNT-A for more than 1 year of follow-up.

CONCLUSIONS

Patients with detrusor underactivity with normal bladder sensation combined with a poor relaxation or hyperactive urethral sphincter were significantly more likely to recover normal detrusor function. Neuromodulation of the hyperactive urethral sphincter by urethral BoNT-A is the likely mechanism for this therapeutic effect.

Prostate botulinum A toxin injection--an alternative treatment for benign prostatic obstruction in poor surgical candidates

OBJECTIVES

To evaluate, in a prospective study, the effectiveness of prostate injection of botulinum A toxin in patients who were poor surgical candidates. Patients with benign prostatic hyperplasia (BPH) are usually successfully treated with medical treatment or transurethral resection. However, some patients with chronic urinary retention or a large postvoid residual urine volume due to BPH are poor surgical candidates or are patients in whom medical treatment has failed.

METHODS

Ten patients with BPH and urinary retention or a large postvoid residual urine volume received 200 U botulinum A toxin injection into the transition zone of the prostate. The clinical results and urodynamic parameters at baseline and after treatment were compared.

RESULTS

All patients had an improvement in spontaneous voiding after treatment. Of them, 8 had an excellent result (80%) and 2 had an improved result. Both voiding pressure and postvoid residual volume were significantly decreased after treatment. The total prostate volume was significantly reduced, and the maximal flow rate was significantly increased after treatment. The maximal effects of botulinum A toxin appeared at about 1 week and were maintained at 3 and 6 months after treatment. At 6 to 12 months (mean 9) of follow-up, no patient had had recurrence of urinary retention and the voiding condition in all patients remained at the post-treatment status. No adverse effect was noted.

CONCLUSIONS

Prostate injection of botulinum A toxin is an effective alternative treatment with minimal adverse effects for patients with benign prostatic obstruction who are poor surgical candidates or in whom medical treatment has failed.

Natural history of detrusor contractility--minimum ten-year urodynamic follow-up in men with bladder outlet obstruction and those with detrusor

OBJECTIVE

To check the long-term effect, in male patients, of treated and untreated bladder outlet obstruction (BOO) on detrusor contractility and to explore the relationship between ageing and detrusor underactivity (DUA).

MATERIAL AND METHODS

Men investigated at the urodynamic department of Southmead Hospital in Bristol between 1972 and 1986 were traced and three groups were invited for repeat pressure-flow urodynamic studies (PFS). The first two groups included patients over 40 years old, with untreated or surgically treated BOO, and the third group had patients with DUA from all age groups.

RESULTS

196 patients (with a minimum 10 year gap from the first assessment) agreed to have repeat PFS. There was no statistically significant change in bladder contractility index (BCI) in patients with BOO treated by transurethral resection of the prostate (TURP) (mean difference in BCI was 0.01, 95% confidence interval -0.07 to 0.09, n=114). There was also no significant difference in BCI in untreated patients with BOO (p=0.10, n=53). The follow-up BCI was higher in untreated patients than in the surgically treated group. The BCI in patients with DUA did not change significantly after a minimum of 10 years' follow-up.

CONCLUSIONS

There is no evidence to suggest that detrusor contractility declines with long-term BOO. Relieving the obstruction surgically does not improve the contractility. This is important when considering and counselling for TURP. Underactive detrusors remain underactive, but do not get worse with time, which could indicate that this is not an ageing process per se and may even have a congenital basis.

CORRELATION BETWEEN DETRUSOR COLLAGEN CONTENT AND URINARY SYMPTOMS IN PATIENTS WITH PROSTATIC OBSTRUCTION

PURPOSE

We used computerized imaging analysis to compare the collagen content of detrusor specimens between patients affected with symptomatic obstructive benign prostatic hyperplasia (BPH) and asymptomatic controls.

MATERIALS AND METHODS

In our study we enrolled 36 patients with symptomatic urodynamically obstructed BPH undergoing transurethral resection of the prostate. We also enrolled 28 men (mean age 61.3, range 55 to 70) undergoing transurethral resection of the bladder for primitive, singular Ta bladder cancer, with no significant urinary symptoms, as the control group. During the transurethral surgical procedure in controls and in patients with BPH, a biopsy was performed deep through the muscular layer from either of the lateral bladder walls. Computerized morphometric analysis of the stained sections was performed with an image analysis system, and a percentage of collagen fibers was extracted through morphological filtering and expressed as a mean percentage of the total bioptic area.

RESULTS

Collagen content in bladder detrusor specimens was significantly higher in patients with BPH compared to controls (48% and 17% of bioptic area, respectively, p <0.001). Mean detrusor collagen content was clearly higher in patients with severe symptoms than in patients with moderate symptoms (50.45 +/- 8.22% and 43.09% +/- 7.05%, respectively).

CONCLUSIONS

Our study supports the important role of detrusor collagen neo-deposition in determining lower urinary tract symptoms in obstructive BPH. Detrusor collagen content correlates with urodynamic obstruction, the presence and severity of symptoms and, given that collagen neoformation is irreversible could probably have a role in the postoperative persistence of lower urinary tract symptoms in patients undergoing surgery for BPH.

Urodynamic study and potassium sensitivity test for women with frequency-urgency syndrome and interstitial cystitis

PURPOSE

The intravesical potassium chloride (KCl) sensitivity test has been used to detect urothelial leakage in patients with frequency-urgency syndrome and interstitial cystitis (IC). It is unclear whether urodynamic studies can predict a positive KCl test. This study compared the urodynamic results for women with different KCl responses who suffered from frequency-urgency syndrome and IC.

METHODS

A total of 196 women suffering from frequency, urgency and/or bladder pain were enrolled in this study. These patients underwent a urodynamic study with a concurrent KCl test. The urodynamic results were compared between the patients who had positive and those who had negative KCl tests and between the patients with and without characteristic IC under cystoscopic hydrodilatation.

RESULTS

Among 196 women, 138 (70.4%) had a positive and 58 (29.6%) a negative KCl test. Among the patients with a positive KCl test, 128 underwent cystoscopic hydrodilatation: 44 were proven to have characteristic IC, and 84 were not. Patients with a negative KCl test had a larger residual urine volume and a higher incidence of poor relaxation of the urethral sphincter than those with a positive test. However, patients with a positive KCl test and proven IC did not differ in urodynamic parameters from non-IC patients. The symptom of bladder pain could not predict a positive KCl test nor characteristic IC either.

CONCLUSIONS

This study shows that no specific urodynamic parameter or specific symptoms can predict a positive KCl test in patients with frequency-urgency syndrome or IC. Patients with bladder pain at full bladder and a positive KCl test had only a 45.2% chance to have characteristic IC.

Analysis of the pathophysiology of lower urinary tract symptoms in patients after prostatectomy

OBJECTIVES

To analyze the pathophysiology of persistent lower urinary tract symptoms (LUTS) in patients after transurethral prostatectomy (TURP).

METHODS

A total of 185 patients who had persistent LUTS after TURP were enrolled into this study. All of these patients underwent multichannel videourodynamic studies and were classified into 6 groups according to the urodynamic results. Preoperative prostate volume, resected adenoma weight, and preoperative Q(max) were determined in each of the groups and the symptomatology and urodynamic findings were compared.

RESULTS

A normal videourodynamic tracing was found in 17 patients (9.1%), pure detrusor instability in 18 (9.6%), low detrusor contractility in 35 (18.7%), detrusor instability and inadequate detrusor contractility (DHIC) in 27 (14.4%), poor relaxation of the urethral sphincter in 36 (19.3%), and bladder outlet obstruction (BOO) in 52 (27.8%). Incontinence was noted in 74 patients (40%), and 18 of them had BOO (24.3%). In urodynamic findings, Q(max) and residual urine showed no significant difference among patients with low contractility, poor relaxation of sphincter, DHIC and BOO. Concerning the preoperative prostatic volume, patients with low contractility, poor relaxation of urethral sphincter, and DHIC had a nonsignificantly smaller prostate volume and resected prostate weight than other groups. Preoperative Q(max) showed no significant difference among all groups.

CONCLUSIONS

Symptoms alone are unreliable in predicting urodynamic findings with respect to obstruction and detrusor instability after TURP. Over half of the patients with persistent LUTS had a small prostate volume and small resected adenoma weight, indicating that some of these patients may not have had BOO. Videourodynamic study is helpful in making an accurate diagnosis for refractory LUTS after TURP.

Voiding dysfunction: definitions

'Lower urinary tract symptoms' is a term that describes symptoms related to both the storage and emptying phases of the micturition cycle. Storage symptoms include urinary frequency urgency, urge incontinence, nocturia, dysuria and other kinds of pain emanating from the bladder or urethra. Emptying symptoms consist of hesitancy, straining to void, difficulty starting, diminished stream, a feeling of incomplete bladder emptying and urinary retention. In both sexes, the etiology of lower urinary tract symptoms is multifactorial, and symptoms are a poor indicator of underlying pathophysiology. In men, lower urinary tract symptoms are most often attributed to prostatic obstruction, but only approximately two-thirds of men with lower urinary tract symptoms meet the accepted diagnostic criteria for obstruction. Approximately half have detrusor overactivity and a smaller number have impaired detrusor contractility, sensory urgency, sphincteric incontinence, polyuria or nocturnal polyuria. In women, lower urinary tract symptoms are often considered to result from hormonal abnormalities, childbirth, aging, or previous surgery, but the multifactorial underlying pathophysiology is similar to that seen in men, except for a much lower incidence of urethral obstruction and a high incidence of sphincteric incontinence. Treatment typically begins with empiric, conservative therapies aimed at resolving detrusor instability or bladder outlet obstruction. However, although either or both of these etiologies may exist in the individual with lower urinary tract symptoms, treatment may fail as a result of another cause. We believe that treatment based on the pathophysiology of the symptoms will lead to better outcomes than treatment based on symptoms alone.